Esophageal varices

Treatment-Activity

As tolerated

Treatment-Diet

As tolerated if varices aren't bleeding Nothing by mouth (NPO) status if varices are bleeding

Treatment-Medications

Beta blockers to reduce pressure in the portal veins Vasopressin to reduce blood flow to all splanchnic organs by potent splanchnic vasoconstriction; somatostatin to stop variceal hemorrhage

Nursing Considerations-Associated Nursing Procedures

Blood and blood product transfusion Blood pressure assessment Esophageal tube care Esophageal tube insertion, assisting Fecal occult blood tests IV bag preparation IV bolus injection IV catheter insertion IV pump use Impaired swallowing and aspiration precautions Intubation with direct visualization Nasogastric tube insertion Nasogastric tube monitoring Oral drug administration Postoperative care Preoperative care Preparing a patient for abdominal surgery, OR Pulse assessment Respiration assessment Stool specimen collection, random Venipuncture

Overview-Causes

Cirrhosis Heart failure Blood clots Sarcoidosis Schistosomiasis Wilson's disease Hemochromatosis Budd-Chiari syndrome

Diagnostic Test Results-Laboratory

Complete blood count (CBC) may reveal anemia, leukopenia, and thrombocytopenia. Prothrombin time (PT) may be prolonged due to liver failure. Liver function test shows mild elevation in aspartate aminotransferase (AST) and alanine aminotransferase (ALT), which may occur due to cirrhosis.

Nursing Considerations-Nursing Diagnoses

Deficient knowledge Excess fluid volume Imbalanced nutrition, less than body requirements Impaired gas exchange Ineffective protection

Overview-Incidence

Esophageal varices are present in 30% of patients with compensated cirrhosis and 60% to 70% of those with decompensated cirrhosis and upper GI bleeding.

Overview-Pathophysiology

Esophageal varices develop when normal blood flow to the liver is blocked in such conditions as cirrhosis. Obstruction of portal venous flow results in increase in portal pressure. The blood backs up into the smaller fragile vessels of the esophagus as well as the stomach and rectum. Back-up of blood into the smaller vessels causes the vessels to swell. Rupture of the vessels may occur, which can lead to a life-threatening condition.

Treatment-Other

Gastroesophageal balloon tamponade, which applies direct pressure to bleeding varices in order to stop the bleeding

Overview-Complications

Hypovolemic shock Encephalopathy Infection

Assessment-Physical Findings

Pallor Hypotension Tachycardia Dyspnea Jaundice Ascites Palmar erythema

Nursing Considerations-Nursing Interventions

Provide support to the patient and family during this difficult time; answer questions that they may have. Provide information regarding the current disease state as well as treatment. Maintain strict intake and output (I&O) records and monitor I&O according to the doctor's order. Encourage small, frequent meals. Provide diet as tolerated. Perform a daily calorie count. Administer oxygen as prescribed. Limit physical activity. Position the patient in a semi-Fowler's or high Fowler's position. Monitor oxygen saturation. Monitor vital signs frequently. Instruct the patient to avoid actions that increase intra-abdominal thoracic pressure, such as coughing, sneezing, and vomiting. Inspect stool for signs of occult blood.

Patient Teaching-Discharge Planning

Refer the patient and family for professional counseling if indicated. Refer patient for possible home health follow-up if indicated. Instruct the patient and family on the importance of keeping follow-up appointments.

Treatment-General

Treatment based on whether varices are bleeding or not Main goal to reduce portal hypertension and blood flow

Diagnostic Test Results-Imaging

Ultrasound of the upper abdomen assesses biliary obstruction or liver cancer. Esophagoscopy evaluates the integrity of the esophagus and is considered the best method to detect varices. Barium swallow verifies the presence of varices.

Treatment-Surgery

Variceal sclerosis or variceal band ligation to stop bleeding varices (endoscopic) Portosystemic shunt procedure used to divert portal blood flow away from the liver

Overview

Varicosities that are prone to rupture and are commonly the source of massive hemorrhages from the upper GI tract and rectum Blood clotting abnormalities, often seen in patients with severe liver disease, that increase the likelihood of bleeding and significant blood loss

Nursing Considerations-Monitoring

Vital signs Intake and output Oxygen saturation Calorie count

Assessment-History

Weakness, tiredness, and general malaise Anorexia Nausea and vomiting Weight loss Abdominal pain Jaundice or dark-colored urine Ascites Pruritus Spontaneous bleeding and easy bruising Muscle cramps

Patient Teaching-General

disorder, diagnosis, and treatment verbal and written information regarding medications (including the drug name, dosage, frequency, precautions, and potential side effects) dietary restrictions lifestyle modifications (including reduction of alcohol intake) signs of bleeding varices importance of follow-up appointments as well as seeking medical attention in the event of bleeding.

Nursing Considerations-Expected Outcomes

verbalize understanding of the disease process be normovolemic 24 hours before discharge demonstrate progress toward adequate nutritional status exhibit adequate gas exchange as shown by a normal arterial blood gas analysis result remain free from esophageal bleeding during his hospital stay.